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2023 HSR&D/QUERI National Conference Abstract

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1120 — Widening rural-urban divide in telehealth use during the COVID-19 pandemic: A national observational study of VA primary care delivery

Lead/Presenter: Lucinda Leung,  COIN - Los Angeles
All Authors: Leung LB (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, US), Yoo CK (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, US) Chu K (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, US; Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, US) Jackson NJ (Division of General Internal Medicine-Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, US) Heyworth LK (Department of Medicine, University of California San Diego School of Medicine, San Diego, CA, US) Der-Martirosian C (Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, US; Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, US)

Objectives:
Telehealth can effectively connect patients to clinicians across distance and time, but its accessibility remains limited for rural populations. The Veterans Health Administration (VA), serving 9+ million patients across 50 states, has long championed telehealth use through national initiatives that distribute electronic tablets to patients for video visits and that provide contingency clinician staffing via telehealth for underserved clinics. VA efforts initially focused largely on rural populations where disparities in health care access and telehealth use existed but have since expanded more broadly with the onset of the COVID-19 pandemic. This study examines rural-urban differences in telehealth use for primary care services across all VA healthcare systems (each VA hospital and associated community clinics) nationally before and after pandemic onset.

Methods:
In an ongoing quality improvement (non-research) effort, we conducted a retrospective study of patients who received primary care (n = 6,340,167) and mental health integration (n = 977,243) services from 138 VA healthcare systems nationwide. We analyzed 63,541,577 primary care (PC) visits and 3,621,653 mental health integration (PC-MHI) visits across 138 VAs nationally, 2019-2021. For each site, we aggregated monthly counts of telehealth (and specifically, video) visits for PC and PC-MHI separately during 12-months before (March 16, 2019-March 15, 2020) and 21-months after pandemic onset (March 16, 2020-December 16, 2021 [1-year after vaccine available]). Telehealth visits included video encounters, telephone calls, and secure messages. We examined whether rurality of VA healthcare system predicted telehealth (and video) use for all primary care-related (PC and PC-MHI) encounters over time, adjusting for VA size (number of patients), age/disability (Charlson Comorbidity Index), and racial-ethnic composition (%Black, %Hispanic) in regression analyses.

Results:
In fully adjusted models, rural VAs initially had higher rates of PC telehealth use than urban VAs (35% vs 29%), which reversed after pandemic onset (56% vs 60%), leading to a 35% reduction in odds of telehealth use over time (CI = 0.55-0.76; p < 0.001). In comparison, the rural-urban gap grew even larger for PC-MHI services (OR = 0.49; CI = 0.36-0.68; p < 0.001), as rural lagged urban telehealth expansion (before 29% vs 25%; after 77% vs 84%). While video use was low overall, the rural-urban divide was stark for PC (OR = 0.28; CI = 0.19-0.40; p < 0.001) and PC-MHI services (OR = 0.34; CI = 0.21-0.56; p < 0.001). Rural VAs initially had higher rates of PC (2% vs 1%) and PC-MHI video use (8% vs 5%) than urban VAs, which reversed after pandemic onset (PC 4% vs 6%; PC-MHI 21% vs 33%).

Implications:
Despite early gains from national telehealth initiatives targeting rural populations, the COVID-19 pandemic exacerbated the rural-urban telehealth divide across the VA. Compared to urban VAs, telehealth expansion lagged for rural sites, especially for specialty PC-MHI services. Video visits still constituted only a minority of clinical services delivered.

Impacts:
VA’s experience demonstrates that a rising tide in telehealth use may not lift all boats, potentially leaving rural populations at risk for poor mental health and primary care access. Future research and implementation efforts can consider better tailoring technology to encourage adoption among rural users at all levels (patients, provider, and health systems), as well as address remaining structural inequities (e.g., internet bandwidth).